This form should be completed by Financial Institutions or individuals applying for information to be redacted from exchange on human rights grounds. The form is not exhaustive and the Financial Institution or individual should use the blank space in section F to draw attention to any other relevant facts, and ensure that relevant supporting documents are sent in with this application form.

For assistance on whether to raise a potential human rights concern please see the Foreign and Commonwealth office guidance on Human Rights internationally:

https://www.gov.uk/government/policies/human-rights-internationally

Please complete a separate form for each relevant jurisdiction for which redaction is being sought.

| Details | |---------| | Name of Financial Institution | | AEOI User ID | | (this can only be obtained after registering for AEOI reporting, see: https://www.gov.uk/government/publications/foreign-account-tax-compliance-act-registration-guidance-fatca) | | Details of persons at risk (names, addresses) | | (If full details are included in supporting documents please include the file name here) | | Relationship of persons at risk to the Financial Institution (e.g. grant recipient of charity) |

| Application: What is the internal situation in the host country and its attitude towards human rights law and international humanitarian law? | |---| | A | Which destination jurisdiction does this application refer to (please complete a separate application form for each relevant jurisdiction)? | | B | What are the specific concerns? Consider the following: | | | 1. Use of the death penalty | | | 2. Unlawful or arbitrary arrest or detention | | | | |---|---| | 3. | Torture or cruel, inhuman or degrading treatment | | 4. | Unlawful killing and/or unlawful use of force | | 5. | Enforced disappearance | | 6. | Unfair trial or denial of justice | | 7. | Unlawful interference with democratic rights (e.g. freedom of assembly or expression) | | 8. | Violations of the rights of the child | | 9. | *Refoulement* (forced return where there is a danger of torture or cruel, inhuman or degrading treatment) | | 10. | Human trafficking and/or sexual violence | | 11. | Persecution of an identifiable group | | 12. | Other violations not already identified |

**C** What activities is the Financial Institution and/or person at risk carrying out in or in relation to the destination jurisdiction?

**D** Please list the evidence that supports the conclusion that sending information to this jurisdiction will result in a threat to human rights.

**E** Please list the supporting documents that accompany this application. This should include evidence of the threat, or similar threats involving the activities of the Financial Institution and/or person at risk and the destination jurisdiction. | | | |---|---| | **F** | Please use this space to detail any other facts relevant to the application, not included above. | | **G** | Contact details for queries. | | | Name | | | Position | | | Telephone number | | | Email address | | **H** | Is the Financial Institution or individual submitting application forms relating to different jurisdictions? Please state how many applications are being made by this Financial Institution or individual. |